Healthcare Provider Details

I. General information

NPI: 1093030280
Provider Name (Legal Business Name): JESSE B MESTON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2010
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-7836
  • Fax: 517-205-5903
Mailing address:
  • Phone: 313-874-4806
  • Fax: 313-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704248727
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9300574
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: